Provider Demographics
NPI:1245355684
Name:SOUTHEAST OPTICAL INC
Entity type:Organization
Organization Name:SOUTHEAST OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:ABO CERTIF OPTICIAN
Authorized Official - Phone:406-234-1447
Mailing Address - Street 1:2000 CLARK STREET
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301
Mailing Address - Country:US
Mailing Address - Phone:406-234-1447
Mailing Address - Fax:406-232-3538
Practice Address - Street 1:2000 CLARK STREET
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301
Practice Address - Country:US
Practice Address - Phone:406-234-1447
Practice Address - Fax:406-232-3538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT29628OtherBLUE CROSS BLUE SHIELD
MT0550001Medicaid
MT29628OtherBLUE CROSS BLUE SHIELD